Becker's Hospital Review

24 POPULATION HEALTH 24 CEO / STRATEGY High-performance design: How improving leadership structures dramatically improved clinical outcomes at Sentara Healthcare By Howard Kern, President and CEO, Sentara Healthcare I n 2018, Norfolk, Va.-based Sentara Healthcare was named one of five large health systems in the Top 15 Health Systems in the U.S. by IBM Watson Health. Our recognition as a top-performing health system came aer we began to understand the importance of delivering highly reliable quality care and a consistently high rate of improvement across our entire health system. Sentara began our quality and safety journey in the 1990s, like many other health systems. While we would observe improvement, we would oen notice varying rates of improvement by facility or group practice. We would also note that our absolute performance, when measured against top performers, would indicate that year-to-year performance was not always improving at a rate as high as the best performers in our industry. We would work hard to improve over a year or two and then find that we were falling back and not sustaining our desired pace of improvement. Health systems can no longer only look internally for improvement opportunities. Adaptation also means looking horizontally, for best practices within or outside your system, and externally outside the healthcare industry. If you are not improving at a rate equal to or better than your peers and competitors, then you are not improving, you are really falling behind! An in-depth self-evaluation helped us realize we were falling behind our high performance peers because of a few root causes. One of them was fragmented implementation. e process of implement- ing best practices was not standardized and coordinated across our 12 hospitals and four medical groups. An illustrative example is the higher rate of urinary tract infections we used to see in our hospitals. Our protocols around catheter removal were not uniform across the system. It took one of our infectious disease specialists over a year of visiting each hospital and attending nearly 30 meet- ings to reach consensus on a unified Foley catheter removal protocol for implementation. Our evaluation found we were making the right decisions most of the time, but we were not executing those decisions as well as we could have. Our siloed leadership structure was partly to blame. Another problem was a lack of organizational discipline to identify and focus on key priorities. We were trying to move the needle on everything, but instead, much to the frustration of our leaders and clinicians, we were not moving the needle significantly on anything. What we need- ed was new guiding principles and a new clinical leadership structure. Our four guiding priciples and clinical leadership structure In 2013, Sentara created a formal process and leadership structure to tackle clinical quality and access improvement in a consistent man- ner across our entire system. First, we established four guiding principles: • Reduce variation in our clinical and operational processes by con- sistently implementing best practices • Prioritize the patient experience • Embed change across the entire continuum of care in all regions • Enhance culture and decision-making tools Next, we transformed our leadership structure from a classic three- legged stool model — where executive leadership, clinical leadership and a network of providers worked in silos — to a high-performance design structure with a direct line of engagement between clinicians and executive leadership. Procedural decisions in this high-performance structure are made by a centralized clinical leadership council with representation from each hospital and division. e council, which meets on a monthly basis, comprises medical staff representatives, executives, hospital presidents and service line leaders from across the system, including our medical group, hospice, at-home and ambulatory care programs. Each member has an equal vote in major decisions to facilitate en- gagement and buy-in. Leadership is now executed in two directions: vertical and horizon- tal. e vertical leadership executes decisions through the hospi- tal president, nurse executive, vice president of medical affairs and medical staff president. ose decisions are then carried horizontally throughout the system by interdisciplinary, high-performance teams that include administrative, nursing, physician and ancillary leaders. Importantly, each team is supported by the same system data and an- alytics. e teams create consistency and a true systemness approach to quality that had evaded Sentara in the past. Eliminating variation and achieving results One of the key focuses of our high-performance teams was improv- ing quality metrics like readmissions, lengths of stay, sepsis and oth- er measures by reducing unwanted variation. ere is a difference between good and bad variation. Some variation is good. You learn through intentional variation. New strategies to improve perfor- mance and the patient experience come from trying different ap- proaches. What is not useful is unmanaged, random variation, like catheter removal times, that lead to poor outcomes. Excellence comes from cutting out unnecessary variation. Our guiding principles, new high-performance leadership structure and focus on removing unintended variation took our hospitals from being all over the map on six key quality indicators to within the same quadrant. It is not an easy task. Even the highest-performing health systems in the U.S. struggle to maintain clinical consistency over 15 or more hospitals. A few key successes to share: • Compared to 2015 baseline numbers, our improved clinical lead- ership structure helped lower readmissions by 13,075. Solutions focused on improving discharge medication adherence, ensuring post-discharge primary care visits within seven days and sending home heart-healthy diet information with patients when they were discharged.

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